Veterans Affairs' $10B Modernization Plan Must Succeed

After nearly 20 years of trying to revamp its health information system, the Veterans Affairs Department has decided to acquire the same electronic health record system the Defense Department is implementing. It appears to be a 10-year process, but if the agency pulls off a massive integration like this, it can set the stage for more holistic VA care.

That’s the future of VA the Oversight and Government Reform IT Subcommittee is eager for. The department spends billions of dollars a year on its information systems, but its attempts to update its Veterans Health Information Systems and Technology Architecture, or VistA, have failed, according to a recent Government Accountability Office report.

What’s the Deal?

VistA was developed in-house and has been running since the 1980s, with more than 200 applications. The problem is, these applications are outdated and increasingly difficult and costly to maintain, and according to the GAO report, VA has “expended extensive resources” to modernize it.

In fact, VA has pursued four VistA modernization initiatives since 2001, with $1.1 billion obligated for contracts with 138 different contractors during fiscal years 2011 through 2016. Prior to the most recent initiative, VA was working on VistA Evolution since 2013.

This effort was supposed to be done by fiscal yearend 2018, and among other things, intended to increase the department’s data exchange and interoperability with the Pentagon and private sector health care partners.

The newest initiative announced in June, however, is scaled “to be the largest implementation of a health care system, [electronic health Record], ever,” Scott Blackburn, VA’s acting chief information officer, said at the Dec. 7 subcommittee hearing. Rather than continuing to modernize VistA, VA plans to buy the same EHR system DOD is implementing through a contract with Cerner Corp.

VA’s New Modernization Plan

According to Blackburn, this will be a $10 billion contract (for the duration of the contract) and will take 10 years to complete. Getting the same product as DOD will allow VA’s and DOD’s patient data to reside in the same system, with the same records. It’ll enable seamless care between the two departments without manual and electronic data exchange between two separate systems. It’s also supposed to minimize customization and system differences currently within the department’s medical facilities.

VA expects to award a contract to Cerner in December, and deployment of the new system is anticipated to begin 18 months after the contract has been signed. The department will incrementally deploy the system to its medical facilities, and each will continue to use VistA until they have the new system.

The goal is to have the new system implemented into all VA medical facilities within seven to eight years after the first deployment. When it’s fully operational, it’ll be the single source for patients to access medical history and for clinicians to use that history in real time at any VA or DOD facility.

But Will History Repeat Itself?

Considering the department’s track record, Rep. Will Hurd, R-Texas and chairman of the subcommittee, has his concerns about this massive undertaking, because he’s eager and adamant about health records being available and up to date, no matter where a veteran chooses to get health care.

“The key difference between previous efforts is we’re going to be buying the commercial, off-the-shelf solution, and absolutely minimizing the customization,” Blackburn said. Redesigning business process to conform with off-the-shelf software will also bring costs down and adopt best practices.

Another concern is that VA has different processes at each one of its 168 medical centers.

“What this will force us to do is standardize across our medical system and then also in line with the workflows of the [Defense Department] in order to implement this off-the-shelf solution,” Blackburn said. DOD and VA doctors will share a single record, making it seamless.

And while VA begins transitioning Cerner, it won’t affect interoperability with previous data. Blackburn said VA will maintain the ability on Cerner to view the records from VistA Evolution via the Joint Legacy Viewer.

This, too, concerned Hurd.

“The JLV is not interoperability,” he said, and while it’s the right move to work toward one system, the people who will ultimately benefit from the new system are still seven years away. What VA and DOD haven't done yet is prove all the data gathered from VistA will be viewable on Cerner.

“There is nothing to date that makes me feel comfortable that we know we can do that,” Hurd said.

There are about 130 versions of VistA operating in VA, so 130 different data sets and architectures.

“How has that been allowed to continue?” Hurd questioned, and “when will we be able to demonstrate, for one record, that we can get the data from a VistA EHR and view if through a Cerner application?”

VA assured it will have initial operating capability in the Pacific Northwest in less than 18 months, with the ability to demonstrate interoperability in a laboratory environment prior to full deployment.

What This Could Mean For Future of VA Care

The Cerner solution will give full interoperability within VA, with DOD and possibly some of Cerner’s private hospital network.

“But it wont give us 100 percent, no solution right now will give us 100 percent with the private sector, that solution doesn’t exist right now,” Blackburn said.

But this is the possibility Hurd sees with the VA and DOD integration success.

“A $10 billion project to integrate 130 different data sets and achieving true interoperability, this will be the model,” Hurd said. “If we’re able to integrate DOD and VA, the two largest health care providers in the world, then we’re going to be able to integrate to every other system.”

This kind of information sharing can even enable virtualized research cohorts based on the information because it will be in the cloud, accessible and protected.

“So this is the opportunity that we have here,” Hurd said. “And if we can’t do it in 10 years, with $10 billion, it’s never going to get done.”

The Modernizing Government Technology Act working capital fund can also help the department get there. Hurd urged VA to move in this direction, because the modernization efforts are so large and there will be recognized savings from such a massive enterprise, which can hopefully help speed up the Cerner implementation.

By putting those savings into a working capital fund, Hurd said it’ll allow VA to do more by giving the CIO shop the motivation to modernize with money saved for other projects.

Lessons Learned

When agencies struggle the way VA has historically with modernization, avoiding similar situations takes the right leadership and processes, Hurd told GovernmentCIO Magazine.

“If they don’t have the right processes in place to oversee the proper implementation, you have people that are making the buying decisions that are not the people involved in utilizing whatever they’re buying, so there’s a disconnect there,” he said.

It’s important leadership understands incremental development, setting milestones every 90 days to make sure the department is moving in the right direction toward full implementation.

“So if you have the right processes in place, and you have good people, then you're going to be successful on a massive project,” Hurd said.

In terms of VA, in 10 years, the department’s current leadership will most likely not be there, so the only way to make sure the project moves in the right direction is to put the processes in place now that will allow it to, regardless of who is in charge.